Optalis Health and Rehabilitation of Canton

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake: 2785066.Based on interview and record review the facility failed to follow physician orders for one (R603) of three residents reviewed for standards of practices resulting in R603 not having a urinalysis collected in a timely manner.Findings include:The State Agency received a complaint that the facility did not follow the physician's order to collect a urinalysis in a timely manner. According to the Electronic Health Record (EHR) R603 admitted to the facility on [DATE] with multiple diagnoses that included history of Urinary Tract Infection (UTI). On 2/5/26 the Nurse Practitioner (NP) B ordered R603 to have a urinalysis (UA) with culture and sensitivity (C&S) sent to the lab for complaints of abdominal pain and history of recurrent UTI. On 2/6/26, Licensed Practical Nurse (LPN) E documented that R603 had refused straight catheterization (tube inserted through urethra into the bladder to drain urine, then immediately removed) and a urine sample could not be obtained. There was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2724140 and 2718825.Based on interview and record review the facility failed to adequately document, monitor and access one resident (R901) out of three residents reviewed for wound care, resulting in the potential for delayed treatment and worsening of R901's frost-bitten feet.Findings include:Record review revealed R901 was admitted into the facility on 1/9/26 with a pertinent diagnosis of pain in right and left foot and frost bite of feet.Record review of R901's Brief interview for Mental Status (BIMS) dated 1/10/26, R901 scored 15/15 reflecting intact cognition.A phone interview was conducted with Family Member (FM) B on 2/11/26 at 12:20 PM, it was reported the resident was admitted to the facility on [DATE] with bandages on both feet. It was further reported that during a visit on 1/10/26, R901's nurse was reminded by the FM B that the resident's bandages had not been changed. On a return visit on 1/11/26 in the morning, when R901's feet were inspected, both feet were still…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to 2663449 and 2668212. Based on interview and record review, the facility failed to ensure resident-to-resident verbal and physical abuse did not occur for two residents (R104 and R105), resulting in verbal and physical abuse. Findings include:Allegations of resident-to-resident abuse were reported to the State Agency. A review of the facility's investigation summary of a resident-to-resident incident between R104 and R105 documented in part the following: On October 11, 2025 at approximately 8:45 PM, R104 and R105 were involved in a physical altercation on the Cherry Hill unit. According to witness statements from staff and other resident, R104 was walking down the hallway returning to her room. R104 began using unprovoked profanity towards the nurse. At that time, R105 had just returned to her room from downstairs. R105 told R104 to be quiet and go back into her room. R104 said to R105, don't tell me what to do. R104 included profanity in her response. R105 said, what did you say? R104…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes 2650924, 2663449, and 2668212.Based on interview and record review, the facility failed to implement policies and procedures for ensuring proper reporting of abuse to the State Agency for four residents (R102, R103, R104, R105) out of eight resident reviewed for abuse, resulting in the likelihood of further abuse and subsequent physical or psychological distress. Findings include:A review of a Facility Reported Incident (FRI) dated 10/6/2025 documented the following: R102 and R103. On 10/6/2025 at 3:00 p.m. the Administrator /Abuse Coordinator was notified by Licensed Practical Nurse (LPN) A that on October 2, 2025, R103 was heard swearing at the roommate R102. LPN A stated that the R103 was irritated and using abusive language with the roommate R102. The FRI continued and the Incident Summary documented: This was brought to the writer's (The Administrator/Abuse Coordinator) attention on today (10/6/2025) however the incident occurred on 10/2/1025. The (R103) as temporarily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure showers for (R104) and grooming (R111) were provided per resident's preference resulting in unmet care needs and resident dissatisfaction. Findings include:R104A review of the clinical record documented R104 was admitted to the facility on [DATE]. R104's diagnoses included cerebral infarction, vascular dementia, and bipolar disorder. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. A review of R104's care plans documented in part the following: ADL (activity of daily living) self-care deficit related to muscle weakness, unsteadiness on feet, behaviors. Date initiated: 5/19/25. Intervention: Assist to bathe/shower as preferred per shower schedule and as needed. Date initiated: 5/20/25. On 11/24/25 at 2:16 PM, Concerned Family Member (CFM) F said R104 had not been getting regular showers. On 11/25/25 at 12:15 PM, Licensed Practical Nurse/Unit Manager (LPN/UM) I said staff are to complete shower sheets…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to 2598018. Based on observations interview, and record review, the facility failed to implement intervention to prevent falls in a timely manner for one resident (R101). Findings include: It was reported to the State Agency that the resident has fallen out of the bed and staff are not always ensuring the resident's bed was kept in a low position. On 11/24/25 at 2:51 PM, R101 was observed awake and lying in bed. The top of the mattress on R101's bed was approximately 24 inches from the floor. R101 said he fell out of bed a couple of months ago and that his left side, arms and legs got a little worse after the fall. On 11/25/25 at 3:37 PM, staff were observed putting R101 in bed. The bed was elevated. On 11/25/25 at 3:40 PM, R101 was observed in bed. The top of the mattress on R101's bed was approximately 20 inches from the floor. A review of the clinical record for R101 documented an admission date of 6/24/25 with diagnoses that included hemiplegia/hemiparesis following cerebral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to 2598018. Based on observation, interview, and record review, the facility failed to ensure nutritional supplement administration and hospital transfer documentation were accurately documented for two residents (R101and R104) and failed to ensure a complete medical record that documented a resident-to-resident altercation for one resident (R104), resulting in the potential for staff and providers lacking accurate information to care for residents. Findings include:R101A review of the clinical record for R101 documented an admission date of 6/24/25 with diagnoses that included hemiplegia/hemiparesis following cerebral infarction, vascular dementia, aphasia, and gastrostomy status. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. R101's diet prescription included a regular diet, soft bite size pieces and a house supplement with meals. Physician orders included administering one can of high-calorie, fiber-fortified liquid supplement if R101 consumed less than…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food contact and non-food contact surfaces were adequately cleaned and sanitized. This deficient practice had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness. Findings include: The following was observed during the initial tour of the kitchen on 8/11/25 at 8:15 AM with Dietary Manager A- The rubber bumper at the base of the reach-in juice cooler was visibly soiled with dust and food stains.- The front drip tray of the commercial ice dispenser was stained with food debris. DM A said the ice machine was not clean. Food debris (collard greens) observed on the inside base of the drip tray was easily removed by DM A. - A full fruit cup, an empty plastic cup, a plastic cup lid, loose paper, and food debris was observed on the floor behind the ice dispenser and reach-in cooler.- Four ladles, hanging from a rack, were stored bowl side up. Each ladle was stained with dried food debris. DM A indicated they needed to be cleaned.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a visually unappealing property and the potential for harborage of pests. Findings include: Based on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a visually unappealing property and the potential for harborage of pests.Findings include:On 8/13/25 at 11:16 AM, the outside dumpster area was observed with Dietary Manager (DM) A. Three dumpsters were in this area. The half lid on dumpster one was flipped open. Dumpster two was pushed up against dumpster three which prevented the lid on dumpster three from closing. Trash and debris of various types and mounds of decaying leaves were piled up behind the dumpsters. A lid from a 55-gallon trash can was wedged underneath dumpster three. The lid of a 55-gallon trash was not fully closed. A pool of standing water was observed on the lid of a large gray square…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the handwashing sink faucet, commercial ice dispenser, and walk-in freezer which had the potential to affect all residents that eat from the kitchen. Findings include:During the initial tour of the kitchen on 8/11/25 at 8:15 AM with Dietary Manager (DM) A the following was observed, the faucet for the handwashing sink did not shut off completely, dripping water was observed coming from the commercial ice dispenser drainage pipe, and the internal temperature of the walk-in freezer was observed to be 12 F (Fahrenheit). A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. The AM recorded temperature on the freezer temperature log for 8/11/25 was 8 F. DM A said he will contact maintenance.During an interview on 8/11/25 at 10:23 AM, Maintenance Director (MD) B said he was unaware of any current leaks in the kitchen. MD B said he fixed a leaky drainpipe on the handwashing sink in the kitchen a while ago but did not know the handwashing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain consent for psychotropic medications (drugs that affect behavior, mood, thoughts, or perception) use for two residents (R2, R4) out of five residents sampled for unnecessary medications. Findings include: R2 Record review of R2's Electronic Health Record (EHR) revealed admission to the facility on 6/11/25 with diagnoses which included aftercare following Joint Replacement Surgery, Major Depressive Disorder, and Neurocognitive Disorder with Lewy Bodies (dementia). Review of R2's Brief interview for Mental Status (BIMS) assessment performed on 7/7/25 revealed a BIMS of 12/15 moderately impaired cognition. R2 had guardianship appointed on 12/13/24. Review of the physician orders revealed Trazadone and Citalopram Hydrobromide (antidepressants/psychotropic medications) were ordered on 6/12/25. Review of R2's care plan revealed At risk for adverse effects related to use of antidepressant medication. Date initiated 6/12/25. Review of the Psychiatric…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure security and accountability for 30 oxycodone-acetaminophen 10-325 mg (milligram) tablets for one resident (R1) of three reviewed for drug diversion of controlled substances, resulting in 30 missing oxycodone-acetaminophen without resolution and a delay in pain relief.A review of the facility's incident report was received by the State Agency via online submission on: 6/23/25 revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg prescribed to resident R1. A total of 30 tablets were unaccounted for during the beginning of the day shift count.Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing.Misappropriation of Controlled Substance (Narcotics) Time of Incident: 11:00a.m.The nurse notified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 1221139 Based on interview and record review the facility failed to report to law enforcement drug diversion of 30 Oxycodone tablets (controlled substances) for one resident (R1) of three residents reviewed for missing medications. Findings include: A review of the facility's incident report was received by the State Agency via online submission on: 6/23/25 revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg (milligram) prescribed to resident R1. A total of 30 tablets were unaccounted for during the beginning of the day shift count.Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing (DON).Misappropriation of Controlled Substance (Narcotics) Time of Incident: 11:00a.m.The nurse notified the pharmacy to get a refill the pharmacy notified the nurse that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure the misappropriation of 30 oxycodone-acetaminophen 10-325 mg (milligram) tablets was thoroughly investigated for one resident (R1) of three reviewed for drug diversion of controlled substances, resulting in 30 missing oxycodone-acetaminophen without resolution and a delay in pain relief. The review of the incident report revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg prescribed) to resident (R1). A total of 30 tablets were unaccounted for during the beginning of the day shift count.Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing.Misappropriation of Controlled Substance (Narcotics) Time of Incident: 11:00a.m.The nurse notified the pharmacy to get a refill the pharmacy notified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure appropriate transfer documentation was in place for one resident (R6) out of one resident reviewed for hospital transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangements upon transfer from the facility. Findings include: A review of the admission Record for R6 documented an initial admission date of 6/18/25 and readmission on [DATE]. R6 was discharged from the facility on 8/5/25. R6's diagnoses included hemiplegia and hemiparesis following cerebral infarction, surgical aftercare following surgery on the nervous system, heart failure, aphasia following cerebral infarction, and adult failure to thrive. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment.On 8/12/25 at 9:52 AM, Unit Manager/Licensed Practical Nurse (UM/LPN) F said R6 was not in the facility (at the time of this interview) because he went out for a procedure on 8/5/25. A review of a physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR - determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability meets the criteria for a nursing home and their needs are met) Level I (3877) was completed for one resident (R4) out of two residents reviewed for PASARR screening. Findings include:A review of the clinical record for R4 documented an original admission date of 10/18/23 and readmission date of 4/23/24. R4's diagnoses included vascular dementia, delusional disorders, major depressive disorder, and psychotic disorder with delusions. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. The PASARR document available in R4's clinical record was dated 7/19/24. This PASARR document indicated in part the following, The recipient may be admitted to or remain in the nursing facility and receive mental health services. Further PASARR Level II…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely pain management for one resident (R120) out of five residents reviewed for pain management, resulting in a shortened therapy session and resident pain and discomfort. Findings include:On 8/12/25 at 10:25 AM R120 was observed sitting in her wheelchair in her room. R120 said earlier in the morning a physical therapist came and took her to therapy before she was able to receive her pain medication. R120 said she was in therapy for only about 10 minutes because she was in severe pain.On 8/12/25 at 10:30 AM Licensed Practical Nurse (LPN) W said a therapist took R120 to therapy before pain medications could be administered. The therapist said they would bring her back in 40 minutes. LPN W said she prefers for R120 to get her meds before going to therapy.On 8/12/25 at 12:01 PM, the Director of Nursing (DON) said that it was not okay that R120 received therapy before she received her pain medications. The DON said both parties, therapy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to provide morning meals for two residents (R62, R91) who attended dialysis out of three residents sampled for dialysis services. Findings include:R62On 8/11/2025 at 11:17 AM R62 and R62's spouse were interviewed regarding dialysis services and R62 said she wasn't given breakfast before or after dialysis nor a snack to take with her this morning. R62's spouse said he usually brings in something for his wife to eat since the facility doesn't provide anything in the morning for her.Record review of R62's Electronic Health Record (EHR) revealed admission to the facility on 7/17/25 with diagnoses which included End Stage Renal Disease, and Dependence on Renal Dialysis.Review of R62's Brief interview for Mental Status (BIMS) assessment performed on 8/1/25 revealed a BIMS of 11/15 moderately impaired cognition. Review of R62's physician orders revealed, Dialysis Treatment .Treatment days Mon, Wed, Fri pick up at 5:45 AM Ensure packed food if needed.Review of R62's care plan revealed, Focus The resident needs hemodialysis related to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted per professional standards of practice for one medication cart (Cherry Hall Cart) of three medication carts observed for medication storage and cleanliness. Findings include On 08/12/2025 at 11:47AM, an observation and interview were conducted with Nurse M's Cherry Hall medication cart. Upon inspection of the medication cart, a total of 12 loose pills were scattered on the bottom of the second drawers. The loose pills varied in shapes, colors and sizes. In addition, the second drawer of the medication cart had a pack of cigarettes and dust.On 08/12/2025 at 11:55 AM, an interview was conducted with Nurse M regarding the loose pills, cigarettes and dust found in their medication cart (Cherry Hall). Nurse G said that the cart should be clean by dayshift and midnight nurses. On 08/12/2025 at 12:18 PM, an interview was conducted with the Director of Nursing (DON) regarding the 12 loose pills, cigarettes and dust found in Cherry Hall medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain the dignity of one (R402) of three residents reviewed for dignity and respect. Findings include: On 7/2/25 at 9:55 AM, R402 was observed sleeping at the [NAME] nurse's station. R402 was observed seated in a wheelchair with her head resting directly on the desk. Nurse Practitioner (NP) F was observed sitting in a different part of the nurse's station actively typing in a computer facing 90 degrees away from R402. No other staff were observed in the area. When NP F was queried regarding R402's positioning NP F said R402 was not her patient, but she had been helping keep her calm. On 7/2/25 at 10:00 AM, Registered Nurse (RN) G was observed passing medications down the 300 hallway. RN G confirmed R402 was under his care for the shift. R402 was not visible from RN G s location. On 7/2/25 at 10:05 AM, R402 was observed with RN G sleeping at the [NAME] nurses' station with her head resting directly on the desktop. When queried about…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance with professional standards of practice for one (R403) of four residents reviewed for medication administration resulting in inaccurate medication administration. Findings include: On 7/2/25 at 10:15 AM, R403 was observed walking out of his room holding a medication cup to his mouth with approximately four pills. R403 was observed alone without staff supervising medication administration. When asked what R403 was doing, R403 stated, I'm taking my pills. R403 dropped one pill on the floor, bent over picked up the pill, placed the pill back in the medication cup. R403 returned to his room where he swallowed the remaining pills from the medication cup. R403 was observed to have a PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients to take in nutrients. On 7/2/25 at 10:30 AM, Licensed Practical Nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that medications were administered via the correct route via PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients who cannot eat normally) for one (R403) of four residents reviewed for medication administration resulting in the potential for silent aspiration (when food, liquid, or other materials are inhaled into the airway without the individual realizing it, potentially leading to serious health issues like aspiration pneumonia and even death). Findings include: On 7/2/25 at 10:15 AM, R403 was observed walking out of his room holding a medication cup to his mouth with approximately four whole pills. R403 was observed alone without staff supervising medication administration. When asked what R403 was doing, R403 stated, I'm taking my pills. R403 dropped one pill on the floor, bent over picked up the pill, placed the pill back in the medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical records were accurate for one (R403) of six residents reviewed for accurate medical records. Findings include: On 7/2/25 at 10:15 AM, R403 was observed walking out of his room holding a medication cup to his mouth with approximately four whole pills. R403 was observed alone without staff supervising medication administration. When asked what R403 was doing, R403 stated, I'm taking my pills. R403 dropped one pill on the floor, bent over picked up the pill placed the pill back in the medication cup. R403 returned to his room where he swallowed the remaining pills from the medication cup. R403 was observed to have a PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients who cannot eat normally). On 7/2/25 at 10:30 AM, Licensed Practical Nurse (LPN) A was interviewed and identified the following pills were given to R403 in a medication cup to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI000149346. Based on observation, interview, and record review the facility to provide shower linens (towels and washcloths) for two residents (R112 and R113) resulting in an unclean, uncomfortable environmental where residents went without shower linens and had to purchase and share personal items. This deficient practice affected all 107 residents residing in the facility. Review of an anonymous intake, dated 1/6/25, noted the following on 1/24/25, Complainant states for at least the past 2 weeks the facility has been without towels and washcloths for the residents. The complainant states staff have been instructed to cut up gowns to use to wash and dry residents. Complainant states they have a loved one at the facility and staff left feces on the resident after attempting to clean them up with a gown. On 2/11/2025 at 09:15 am, an observation of the linen closets on each unit revealed the following: -Cherry Hill- zero towels and zero washcloths -Medbridge- three towels and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00149294. Based on interview and record review, the facility failed to ensure that private property was protected from theft by an employee for one resident (R102) of five reviewed for misappropriation of property, resulting in an employee's deliberate removal of R102's earbuds from possession. Findings include: A facility reported incident revealed the following, Facility investigation report received via online submission on: 12/27/24, 10:21 AM Incident Summary Resident [R102] who is with us [Facility]for short-term Rehab care reported to the DON [Director of Nursing] that [R102] left [their] room to go to activities and left [their] apple air pods [wireless earbuds] in [their] room. Upon resident [R102] return to [their] room they were nowhere to be found, and [R102] then activated an app to help [R102] locate them in switch they started to make a tracking noise. Where [R102] tracked to a housekeepers cleaning cart. Investigation Summary Date of Event: 12/23/2024 Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00149008 and MI00148990. Based on interview and record review, the facility failed to ensure proper transfer assistance for two residents (R102 and R103) out of four residents reviewed for accidents. Findings include: R102 - It was reported to the State Agency that the facility failed to ensure proper transfer assistance. The complainant indicated that the resident fell to the floor while being transferred back into the bed and a nurse assistant and nurse were rough with the resident during the transfer from the floor into the bed. A review of the clinical record for R102 documented an admission into the facility on [DATE] and discharge on [DATE]. R102's diagnoses included ovarian cancer and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Record review of R102's ADL (activity of daily living) self care deficit as evidence by weakness related to metastatic CA (cancer) care plan documented transfer with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the correct amount of TPN (total parenteral nutrition used to provide complete nutrition directly into the bloodstream) was administered for one resident (R102), out of three residents reviewed for altered methods of receiving required nutrients. Findings include: A review of the clinical record for R102 documented an admission into the facility on [DATE]. R102's diagnoses included ovarian cancer and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Record review of R102's care plans documented resident was at nutritional risk related to diet restrictions, recent hospitalization, unplanned/unexpected weight loss, recurrent ovarian cancer, abdominopelvic abscess with blockage, history of nausea/vomiting, abnormal labs, history of multiple transfusions, gastrointestinal bleed, depression, severe protein-calorie malnutrition, fragile skin with drains, pedal edema, requires TPN,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to consistently change the PICC (peripherally inserted central catheter) line tubing according to physician's order for one resident (R102) out of three residents reviewed for altered methods of feeding. (The parenteral method delivers nutrition intravenously which increases the risk of infection). Findings include: A review of the clinical record for R102 documented an admission into the facility on [DATE]. R102's diagnoses included ovarian cancer and severe protein-calorie malnutrition. A Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition. Record review of R102's potential for complications at IV (intravenous line) insertion site. PICC inserted at upper right arm, care plan indicated to change IV tubing per physician orders, initiated 12/5/24. Physician's order documented to Change IV PICC line tubing daily every day shift for safety monitoring. Start date of 12/6/24. A review of R102's Skin assessment dated [DATE] documented in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00147516. Based on interview and record review the facility failed to inform a cognitively impaired resident's representative of a change in condition for one resident (R902) out of three residents reviewed for resident's rights, resulting in a missed opportunity for R902's representative to participate in medical decisions. Findings include: Record review of R902's electronic medical record (EMR) revealed admission into the facility on [DATE] with diagnoses of dementia, pressure ulcers, and chronic kidney disease. According to the Minimum Data Set (MDS) dated [DATE], R902 was dependent with all Activities of Daily Living (ADLS). Further review of a Brief Interview for Mental Status (BIMS) dated 10/4/24, documented that R902 had scored 3 out of 15 (severe cognitive impairment). R902's facesheet identifieda resident representative. Review of Skin and Wound Evaluation dated 10/7/24, indicated R902's pressure ulcer on coccyx had worsened and categorized to a Stage III- Full-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00147516. Based on interview and record review the facility failed to identify a resident with dentures and implement adequate oral care for one resident (R902) out of three residents reviewed for Activities of Daily Living (ADLs). Findings include: Record review of R902's electronic medical record (EMR) revealed admission into the facility on [DATE] with diagnoses of dementia, pressure ulcers, and chronic kidney disease. According to the Minimum Data Set (MDS) dated [DATE] documented that R902 was dependent with all Activities of Daily Living (ADLS). Further review of a Brief Interview for Mental Status (BIMS) dated 10/4/24, documented that R902 had scored 3 out of 15 (severe cognitive impairment). Record review of facility admission Evaluation dated 10/4/24, it was documented under oral evaluation section that R902 did not have dentures. Review of R902's care plan revealed no interventions to remove and clean dentures. Review of R902's [NAME] (Information noted to perform…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00146875. Based on interview and record review the facility failed to follow a physician's order in a timely manner to insert an indwelling urinary catheter for one (R805) of three residents reviewed for quality of care resulting in the potential for the resident to develop a urinary tract infection. Findings include: The State Agency received a complaint that the facility failed to assess a resident (R805) for a change in condition in a timely manner resulting in the resident being hospitalized for Urinary Tract Infection in less than 24 hours after discharge from the facility. According to R805's Electronic Health Record (EHR) the resident admitted to the facilty on 8/7/24 with multiple diagnoses that included fractured left tibia (top shin bone), fractured left fibula (lateral/outer shin bone), fractured left foot, and fractured lower end of right femur (above knee). R805 had a history of urinary retention, obstructive and reflux uropathy. According to the Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intakes MI00144625 and MI0014484. Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to meet the needs of residents' dependent upon staff for care needs. This deficient practice has the potential to affect all 72 residents that reside at the facility. On 7/9/24 at 9:52 a.m. during the Entrance Conference, it was confirmed the resident census was 72 (32 residents on the second floor; 40 residents on the first floor). On 7/09/24 at 10:46 a.m. during the initial pool process, the second floor had two nurses and two nurse aides to provide care for 32 residents. On 7/9/24 at 10:50 a.m. Unit Manager H said there is usually two nurse aides for 32 long term residents. Unit Manager H was not able to confirm the number of residents that required two-person assistance with care (transfers, bed mobility, showers, toileting). LPN T said there are three nurse aides at times but there are usually just two. LPN T did not respond to the inquiry of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure a Registered Nurse (excluding the Director of Nursing) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 72 residents in the facility. Findings include: On 7/12/24 9:46 a.m. review of the nurses' schedule for the month of June 2024, revealed there was no Registered Nurse (RN) coverage on June 1st through June 3rd (Saturday-Monday). On 7/12/24 at 10:32 a.m. during an interview with the Staffing Coordinator R who confirmed, on June 1st and 2nd there was no RN coverage, and the Director of Nursing came in to provide coverage. On June 3rd the RN that was scheduled to come in called off and the Director of Nursing had to come in to cover. On 7/12/24 at 11:05 a.m. The Director of Nursing was interviewed and confirmed there was no RN coverage for the dates of June 1st-3rd due to call offs and came in to provide coverage, I was later…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to provide accurate and complete information for Advance Medical Directives (AMD), legal documents that allow a person to identify decisions about end-of-life care ahead of time, for eight residents (R12, R15, R16, R17, R19, R21, R40, and R55) of 12 residents reviewed for AMDs resulting in the resident or their Legal Guardian (LG) not being fully informed of how to formulate an AMD and their preferences for medical care not to be followed by the facility. Findings include: R12 According to R12's Electronic Health Record (EHR), the resident admitted to the facility with multiple diagnoses that included history of a stroke and chronic obstructive pulmonary disease. The EHR's header (top of page) indicated R12 was a full code. (All medical measures will be take to maintain and resuscitate life including Cardio Pulmonary Resuscitation if the resident has no heartbeat and not breathing.) R12 had a Legal Guardian (LG) with valid paperwork and contact information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure dignity was maintained for one resident (R21) of three residents reviewed for dignity, resulting in the resident expressing feelings of embarrassment and humiliation. Findings include: In an interview on 7/9/24 at 12:40 P.M., R21 explained that on Friday 6/21/24 he had been taken to physical therapy wet. R21 reported he told the PTA (Physical Therapy assistant) G he had an accident and his sheets and briefs needed to be changed. According to R21 PTA G did not assist or request staff assistance in changing the resident's brief, but did ask the two nurse aides at the desk to change the resident's linen on the bed before the resident returned to the unit. During the interview R21 began to cry uncontrollably stating he was taken to therapy and had to wear a wet brief for 45 minutes or more and he felt embarrassed and humiliated. The resident continued and repeatedly commented, I am a human being, well respected in my church and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide showers for one (R21) of five residents reviewed for Activities of Daily Living (ADL'S), resulting in the resident not receiving scheduled showers. Findings include: In an interview on 7/9/24 at 12:40 P.M., R21 stated, he was admitted to the facility on [DATE] and for 2 and half weeks after admission had not received a shower. R21 stated he got so frustrated his wife came to the facility and gave him a shower because the staff was ignoring his requests for a shower. The resident was queried, if he told anyone about his showers, R21 responded yes, it was reported to the concierge (corporate liaison from outside who take concerns in the facility 2-3 times a week) and R21 did not receive the shower promised on that Saturday night. R21 indicated the staff continued to give me a bucket bath (meaning bed bath). Review of the admission Face Sheet indicated R21 was admitted to the facility on [DATE] with pertinent diagnoses of: Heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation contains two Deficient Practice Statements. Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to effectively communicate and collaborate care with hospice staff for one resident (R28) reviewed for hospice services resulting in R28 not receiving an Alternating Pressure Relief Mattress (APM). Findings include On 7/10/24 at approximately 4:00 PM, R28's family member said the resident was supposed to receive a pressure relieving mattress (APM) from hospice for comfort care about a month ago and had not received it. R28 was observed in a bariatric sized bed (a wider bed) with a regular bariatric mattress in place, not an APM. It was noted that an APM was outside the resident's room, leaning against the wall. Review of R28's Electronic Health Record (EHR) indicated R28 had multiple diagnoses that included adult failure to thrive, dementia, and was receiving hospice services. A care plan for 'hospice' was initiated on 3/19/24 included the following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to schedule an ophthalmologist (eye doctor) appointment for one resident (R12) reviewed for vision services resulting in R12 having delayed treatment for cataracts. Findings include: On 07/09/24 at 10:20 AM, R12 was observed laying in bed watching TV. R12 had several books, magazines, word search puzzles, and an IPad on his over-bed table. Upon inquiry R12 said, I like to read and play games on my IPad, but I can't see that well because I have cataracts. I've asked them several times to make me an eye doctor appointment, but nothing gets scheduled. According to R12's Electronic Health Record (EHR), the resident admitted to the facility with multiple diagnoses that included history of a stroke and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) dated [DATE], indicated the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14/15. On 6/5/24, a progress note written by Nurse Practitioner (NP)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to label tube feeding (liquid nutrition provided by a tube to stomach) container and hydration flush bag for one resident (R60) out of two residents reviewed for nutrition, resulting in the potential for receiving the incorrect product and dosage. Findings include: During an observation on 7/9/24 at 10:19 AM in R60's room, a bottle of Glucerna (Liquid nutrition) was infusing as well as a hydration bag. The bottle of Glucerna was not labeled with the date started, resident's name or the physician's order for infusing. The hydration bag was not labeled with resident's name, date, order for flush or the contents of the bag. Record review of R60's electronic medical record (EMR) revealed resident was admitted into the facility on 6/19/24 with pertinent diagnosis of gastrostomy status (insertion of a tube feeding). According the Minimum Data Set (MDS) dated [DATE], R60 had impaired cognition with a Brief Interview for Mental Status (BIMS) of 5/15.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that the facility responded to pharmacist Medication Regimen Review (MRR) recommendations timely for one resident (R8) of five residents reviewed for a medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes. Findings include: On 7/11/24 at 9:57 a.m. review of the clinical record documented R8 was initially admitted into the facility on 5/26/20 and readmitted on [DATE] with diagnoses that included major depressive disorder, heart failure, generalized anxiety disorder, and morbid obesity. According to the quarterly Minimum Data Set assessment dated [DATE], R8 had intact cognition and required extensive two-person assistance with activities of daily living. Review of R8's physician orders documented the resident's current medications as follows: -Buspirone HCl Oral Tablet 15 MG (Buspirone HCl)- Give 1 tablet by mouth every 8 hours for Anxiety.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #144271 Based on interview and record review the facility failed to obtain blood glucose levels per physician orders effecting one resident (R901) out of three residents reviewed for change in condition, resulting in unmonitored blood glucose levels. Review of an admission Record revealed, R901 admitted to the facility on [DATE] and discharged on 4/30/24 with pertinent diagnosis which included Sepsis, Type 2 Diabetes, and Severe Sepsis with Septic Shock. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R901 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required parenteral nutrition. Review of Physician orders revealed R901 had orders which included: Blood Sugar check two times a day for DM (diabetes mellitus) with a starte date of 4/14/24 and an end date of 5/3/24. TPN (Total Parenteral Nutrition) Electrolytes Intravenous Concentrate (Parenteral Electrolytes) use 75 ml/hr intravenously every 24 hours for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00143275. Based on interview and record review, the facility failed to report an allegation of abuse for one resident (R502) of four residents reviewed for abuse. Findings include: A review of a facility investigation report for R502 revealed the following: Description of the incident: R502 alleged that someone around 8:00 AM, a heavy woman, tried to wake her up. R502 said, 'It felt like a bull laid on me.' Summary of the investigation: LPN (Licensed Practical Nurse) A was providing care. Took (R502's) blood pressure and gave her two breathing treatments. Note, LPN A had to reach over to put facemask and apply breathing treatment. Timeline of Events per review of cameras. At 8:22 AM LPN A was seen with the blood pressure machine and entered resident room. At 8:25 AM LPN A came out of room and prepared medication. At 8:29 AM LPN A entered the resident room with medication and breathing treatment. A review of R502's EMR (Electronic Medical Record) revealed R502 was admitted to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00143275. Based on interview and record review, the facility failed to investigate an allegation of abuse for one resident (R502) of four residents reviewed for abuse. Findings include: A review of a facility investigation report for R502 revealed the following: Description of the incident: R502 alleged that someone around 8:00 AM, a heavy woman, tried to wake her up. R502 said, 'It felt like a bull laid on me.' Summary of the investigation: LPN (Licensed Practical Nurse) A was providing care. Took (R502's) blood pressure and gave her two breathing treatments. Note, LPN A had to reach over to put facemask and apply breathing treatment. Timeline of Event per review of cameras. At 8:22 AM LPN A was seen with the blood pressure machine and entered resident room. At 8:25 AM LPN A came out of room and prepared medication. At 8:29 AM LPN A entered the resident room with medication and breathing treatment. A review of R502's EMR (Electronic Medical Record) revealed R502 was admitted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00141653. Based on interview and record review the facility failed to administer intravenous fluids ordered by physician for one resident (R303) out of three residents reviewed for medication administration, resulting in R303 not receiving intravenous fluids as ordered by the physician. Findings include: Record review of electronic medical records (EMR) revealed R303 was admitted into the facility on [DATE] with a primary diagnosis of muscle wasting and atrophy and aftercare following digestive surgery. According to the Minimum Data Set (MDS) dated [DATE], R901 had intact cognition and was provided with partial to moderate assist with Activities of Daily Living (ADLS). Review of Progress Notes dated 11/13/23 at 7:38 PM noted: MD (Medical Doctor) in order IV (intravenous) access initiated for fluids. Sodium chloride to run at 100 cc (cubic centimeters) /hr. for 2 days. Orders processed waiting IV placement. Electronically signed by Register Nurse (RN) B. Review of Progress Notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to ensure the Cherry Hill shower room was maintained in a clean and sanitary manner, resulting in the potential to spread harmful pathogens and residents' environment not being clean and homelike. Findings include: It was reported to the Stage Agency that resident shower rooms were not clean. During an interview and observation of the Cherry Hill shower room on 12/11/23 at 12:31 PM with Certified Nurse Aide (CNA) H, used tissue paper, that appeared somewhat dry, was observed on top of a shower chair seat/commode, wedged underneath the seat/commode, and lying on the bottom front frame of the shower chair. CNA H said the tissue paper looked like it was stained with urine. CNA H stated, The shower chair should have been cleaned after use. On 12/12/23 at 12:52 PM, the Director of Nursing said that shower rooms should be cleaned up after use. A review of a facility policy titled, Showering, dated 2/1/03, revealed in part, Clean the shower room, leaving it in order and ready for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to properly clean resident refrigerators, date-label opened food, and remove expired/undated food from two resident refrigerators, resulting in the potential for food borne illness. Findings include: It was reported to the State Agency that the nourishment rooms were not cleaned. On 12/11/23 at 8:48 AM the Medbridge Nourishment Room was observed with Unit Manager Nurse (UM) C. The following was noted: - The rug in front of the ice machine was soiled and dirty. UM C stated, The rug needs to be vacuumed. - The soap dispenser near the handwashing sink was empty. - The outside of the resident refrigerator was soiled. UM C stated, It's very dirty. The inside of the refrigerator was soiled with a dried red fluid. UM C stated, It needs to be cleaned. - A 48 oz. container of cranberry juice cocktail was opened and undated in the resident refrigerator. - The following food items stored in the resident refrigerator were identified as belonging to a resident by UM C: 1. Two bags of an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake MI00139751. Based on interview and record review, the facility failed to develop a skin alteration care plan for one resident (R420) of five residents reviewed for pressure ulcers, resulting in the potential for the resident to not receive the proper interventions/treatment. Findings include: A review of R420's EMR (Electronic Medical Record) revealed R420 was admitted to the facility on [DATE] and discharged from the facility on 9/26/23. R40 had medical diagnoses that included: disorder of muscle, type 2 diabetes, and encephalopathy (disease that disrupts brain function causing confusion and altered mental status). A review of R420's MDS (Minimum Data Set) dated 9/18/23 revealed R420 had a BIMS (Brief Interview of Mental Status) score of 15/15 (cognitively intact). According to the MDS, R420 had the possibility of developing pressures but at the time of the MDS, R420 did not have any pressure ulcers. A review of R420's orders revealed the following orders: - Wound consult- right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00136584, MI00138968, MI00140212, and MI00140483. Based on interview and record review, the facility failed to provide showers according to resident's preference and/or on their scheduled shower days for three (R403, R416, and R426) of fifteen residents reviewed who were dependent on staff for performance of activities of daily living (ADLs), resulting in untimely and unmet care needs regarding personal hygiene. Findings include: It was reported to the State Agency that residents were not receiving regular showers. Resident #416 On 12/11/23 at 10:00 AM, a review of complaint intake related to Resident #416 (R416) documented resident was not showered in a timely manner. Record review of R416's face sheet revealed admitted to facility on 6/29/23 diagnoses included Covid-19, fall, diabetes mellitus type 2, Atrial fibrillation, hypertension, high cholesterol, psychotic disorder, congestive heart failure, and disorder of muscle. Review of the Minimum Data Set (MDS) dated [DATE] for R416…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to MI00140212. Based on interview and record review, the facility failed to consistently document the provision of meal assistance for one resident (R426), deemed to be at nutrition risk, out of eleven residents reviewed for food intake/feeding assistance, resulting in the potential for additional nutrition concerns to go undetected and compromise in nutritional status. Findings include: It was reported to the State Agency that facility staff failed to provide meal assistance for a resident. A review of the admission Record for Resident #426 (R426) documented an admission date of 9/16/23. R426 discharged from the facility on 10/31/23. R426's diagnoses included cancer of the vulva (external female genitals), lungs, bladder, and bone, moderate protein-calorie malnutrition, congestive heart failure, type 2 diabetes mellitus, and dementia. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A MDS assessment dated [DATE] documented extensive one-person physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, plumbing, and an accessible hand sink, resulting in the potential contamination of food and equipment, and potential for discouragement of hand hygiene, affecting all residents who consume food from the kitchen. Findings include: On 5/02/23 at 10:29 AM, a dried spill and food splatter was observed in the dry storage room at the wall/floor juncture near the can shelf. An unknown substance was observed to have a solidified drip hanging from the wire rack at the same location. According to the 2017 FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B)Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 5/02/23 at 10:31 AM, food debris and grease were observed to be accumulating in the top and bottom drawer of the three-tier drawer near the preparation sink, where…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to: 1. Ensure staff adhered to contact precautions during meal pass; 2. Ensure a meal cart was properly cleaned and sanitized for meal distribution to the residents; and, 3. Educate residents on the risks of sharing electronic cigarettes. These deficient practices resulted in the potential for the spread of harmful pathogens among the residents in the building. Findings include: - Isolation precautions and meal cart On 5/2/2023 at 12:21 PM, a meal tray was observed removed from the room of a resident on contact precautions (transmission-based measures implemented to a resident known or suspected to be infected with a microorganism that can be transmitted by direct contact with other residents or indirect contact with environmental surfaces) for Clostridium difficile (C-diff: symptomatic infection due to the spore forming bacteria causing watery diarrhea). Certified Nurse Aide (CNA) M donned personal protection equipment (PPE) upon entering…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intakes MI00134525, MI00134776, MI00135107, and MI00135738. Based on observation, interview, and record review, the facility failed to provide shaves, nail care, and scheduled showers for seven residents (R26, R73, R228, R248, R429, R480, and R487) out of ten residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs, a feeling of frustration, and the potential for loss of dignity. Findings include: R430 On 5/2/2023 at 11:27 a.m., R430 was observed lying in bed alert and able to be interviewed. R430 was observed with long facial hairs. During an interview, R430 stated, I would love to have a shave because I do not want all the hair on my face. My roommate gets shaved and got one yesterday, but he ended up putting his own shaving cream on and did his own shave. I always had a shave, and they only gave me one shower since I been here. R430 was asked does the staff ask to assist with shaves? R430 stated, They never ask to help shave me, even when I got the one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to Intake MI00134180. Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for multiple residents on the Medbridge Unit, Resident #65, an unidentified resident, and four out of seven anonymous residents attending a Resident Council Meeting, resulting in resident hunger, dissatisfaction with the meal experience, and the potential for unmet nutritional needs. Findings include: A complainant reported to the State Agency that the facility failed to serve palatable food. In an interview during the resident council meeting on 5/3/2023 at 3:00 PM, four out of seven residents reported the food was not warm when trays arrived for meals. During an observation and interview on 5/4/2023 at 8:21 AM, the last tray on the Medbridge Unit meal cart was obtained and used as a test tray. The Minimum Data Set (MDS) Coordinator A was present during the testing of food temperatures on the breakfast tray. The following temperatures were obtained using a metal stem thermometer: Sausage link #1: 113 ºF…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to Intake MI00135738. Based on interview and record review, the facility failed to conduct an initial care conference for one resident (R248) of two residents reviewed for choices, resulting in the missed opportunity for the resident and/or resident representative to participate in the care planning process and make choices about the resident's daily life. Findings include: It was reported to the State Agency that the resident representative was not contacted to discuss plans and goals of care for the resident. A review of the clinical record for Resident #248 (R248) revealed an initial admission date of 2/24/2023 and readmission date of 3/22/2023 with diagnoses that included unspecified disease of the digestive system, depressive disorder, and anxiety disorder. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. A review of clinical progress notes for R248 revealed in part the following: - 2/24/2023 nursing: .Pt. is A&Ox3 (patient is alert and oriented to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

This citation pertains to Intake MI00133152. Based on observation, interview, and record review, the facility failed to administer medications timely and per physician's orders for one resident (R59) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken properly. Findings include: In an observation and interview on 5/9/23 at 11:05 a.m., Licensed Practical Nurse (LPN) O prepared medication for Resident #59 (R59). The medication administration screen had red boxes on each medication. LPN O placed Amlodipine (treats high blood pressure), Aspirin, Plavix (prevents blood clots), Levetiracetam (anticonvulsant), Multivitamin-Minerals, and Senexon-S (prevents constipation) in a medication cup and poured MiraLAX (prevents constipation) in a cup. LPN O entered R59's room and administered the medication and exited the room. LPN O documented the medication administration. When asked if the medication was administered late, LPN O stated Yes. I got behind this morning. In an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake number MI00135633. Based on interview and record review, the facility failed to provide transportation for one resident (R431) scheduled for a follow up orthopedic appointment out of one resident reviewed for appointments, resulting in the potential for a delay and frustration in treatment due to multiple missed appointments by the facility. Findings include: Review of the Electronic Health Record (EHR) revealed Resident #431 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of multiple fractures of ribs from a motor-vehicle accident and pain in left and right knees. R431's admission Minimum Data Set (MDS) with a reference date of 3/7/2023 indicated R431 had intact cognition with a BIMS (brief interview for mental status) score of 15/15, required extensive assistance of two persons with transfers and bed mobility, extensive assistance of one person for toileting, dressing and hygiene. Review of the ADL care plan created on 3/3/2023…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide timely PICC (peripheral inserted central catheter) line/dressing changes, label an IV (Intravenous, therapy that delivers liquid substances directly into a vein) bag, date an IV tubing, and obtain physician's order for PICC line maintenance for two residents (R43 and R485) reviewed for IV Parenteral fluid resulting in the potential for medication delay and error and a bacterial infection originating at the PICC line site. Findings include: R43 On 5/3/2023 at 1:10 p.m., a bag of IV solution was observed hanging at R43's bedside with no label on the bag and no date on the IV tubing. R43 was observed with a right arm PICC dressing dated 4/23/2023 which appeared soiled and not adhered to the skin. On 5/3/2023 at 4:30 p.m., the Director of Nursing (DON) was interviewed in R43's room while observing the unlabeled IV bag, undated IV tubing, and the 4/23/2023 dated PICC dressing. The DON was asked about the frequency of a PICC line…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a physician responded to a pharmacy recommendation for one resident (R26) out of five residents reviewed for pharmacy recommendations resulting in a missed opportunity for collaboration on a medication recommendation and the potential for unmet medical care needs. Findings include: A review of the clinical record revealed Resident #26 (R26) was admitted into the facility on 1/27/2022. R26's diagnoses included congestive heart failure, atrial fibrillation, and anxiety disorder. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of a Medication Regimen Review (MRR) for R26 dated 1/9/2023 revealed the following recommendation: The National Osteoporosis Foundation recommends an intake of 800 - 1000 units of vitamin D per day for adults age [AGE] and older. Please consider Vitamin D 1000 units daily. During an interview and record review on 5/8/2023 at 1:45 PM, Unit Manager (UM) F revealed that R26 did not receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to develop and implement a smoking policy that addressed the use of electronic cigarettes (e-cigs) for residents of the facility. This deficient practice resulted in two residents (R128 and R230) using e-cigs on the property of a non-smoking facility and staff not being adequately educated about the use of e-cigs. Findings include: During an observation and interview on 5/4/2023 at 1:00 PM with Unit Manager (UM) F, Resident #128 (R128) and Resident #230 (R230) were observed on the facility's front patio using electronic cigarettes. Registered Nurse (RN) H was sitting on the front patio with the two residents. UM F stated, They are not allowed to use those within 150 feet of the building. During an interview on 5/4/2023 at 2:12 PM, RN H said when R230 wanted to vape (use her e-cigs), he got her vapor pens from the unit manager. R230, her friend (R128), and RN H went out on the front patio. According to RN H, he informed R230 that they were not allowed to smoke within 150 feet of the property. R230 told RN H that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.